Failure to Provide Foley Catheter Care and Monitoring Resulting in Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and monitoring for a Foley catheter, resulting in an avoidable pressure injury at the catheter insertion site for one resident. Upon readmission, the resident had a Foley catheter in place due to obstructive uropathy and was cognitively intact. Throughout the resident's stay, there were no documented physician orders, care plans, eTAR entries, Point of Care tasks, or Kardex guidance related to Foley catheter care, monitoring, or securement. Progress notes and assessments also lacked documentation of catheter care or monitoring. The resident experienced severe, unrelieved pain at the catheter site, which was not alleviated by prescribed interventions, and exhibited signs of distress such as anxiousness, restlessness, and verbalizing discomfort. The resident was eventually transferred to the hospital, where it was noted that the catheter and surrounding area were unclean, and a significant meatal erosion was identified at the insertion site. Hospital records indicated that exchanging the Foley catheter resolved the resident's pain, and a mucosal membrane pressure injury (MMPI) was diagnosed. Interviews with facility staff confirmed that expected protocols for Foley catheter care and monitoring were not in place or followed for this resident.